Infectious Complications in Infective Endocarditis

  • Bradley Hayley
  • Kwan Leung Chan


Endocarditis has protean systemic and cardiac manifestations. The infective vegetation mediates a destructive process which can involve the cardiac valves and/or perivalvular region. Valvular complications can vary from leaflet erosion or perforation to diverticulum formation, while perivalvular involvement includes abscess, perivalvular regurgitation, pseudoaneurysm and fistula. Transesophageal echocardiography is the preferred imaging tool in the diagnosis of both valvular and perivalvular complications. Prompt detection of these complications is crucial to the timing of surgery and the surgical approach.


Vegetation Abscess Valvular perforation Valvular diverticulum Fistula Echocardiography Computed tomography 


  1. 1.
    Hoen B, Duval X. Clinical practice. Infective endocarditis. N Engl J Med. 2013;368(15):1425–33.CrossRefPubMedGoogle Scholar
  2. 2.
    Osler W. The principles and practice of medicine : designed for the use of practitioners and students of medicine. 14th ed. New York: Appletone; 1942.Google Scholar
  3. 3.
    Chan KL, Dumesnil JG, Cujec B, Sanfilippo AJ, Jue J, Turek MA, Robinson TI, Moher D. Investigators of the multicenter aspirin study in infective endocarditis a randomized trial of aspirin on the risk of embolic events in patients with infective endocarditis. J Am Coll Cardiol. 2003;42(5):775–80.CrossRefPubMedGoogle Scholar
  4. 4.
    Kang N, Wan S, Ng CSH, Underwood MJ. Periannular extension of infective endocarditis. Ann Thorac Cardiovasc Surg. 2009;15(2):74–81.PubMedGoogle Scholar
  5. 5.
    Keynan Y, Rubinstein E. Pathophysiology of infective endocarditis. Curr Infect Dis Rep. 2013;15:342–6.CrossRefPubMedGoogle Scholar
  6. 6.
    McKinsey DS, Ratts TE Bisno AL. Underlying cardiac lesions in adults with infective endocarditis the changing spectrum. Am J Med. 1987;82(4):681–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Rohmann S, Erbel R, Darius H, et al. Prediction of rapid versus prolonged healing of infective endocarditis by monitoring vegetation size. JASE. 1991;4:465–74.Google Scholar
  8. 8.
    Buchbinder NA, Roberts WC. Left-sided valvular active infective endocarditis. A study of forty-five necopsy patients. Am J Med. 1972;53(1):20–4.CrossRefPubMedGoogle Scholar
  9. 9.
    Lester SJ, Wilansky S. Endocarditis and associated complications. Crit Care Med. 2007;35(8 Suppl):S384–91.CrossRefPubMedGoogle Scholar
  10. 10.
    Anguera I, Miro JM, Evangelista A, Cabell CH, San Roman JA, et al. Periannular complications in infective endocarditis involving native aortic valves. Am J Cardiol. 2006;98:1254–60.CrossRefPubMedGoogle Scholar
  11. 11.
    Li J, Sexton D, Mick N, et al. Proposed modifications of the duke criteria for the diagnosis of infective endocarditis. Clin Inf Dis. 2000;30:633–8.CrossRefGoogle Scholar
  12. 12.
    Suty C, Celard M, Le Moing V, et al. Preeminence of staphylococcus aureus in infective endocarditis: a 1-year population-based survey. Clin Infect Dis. 2012;54(9):1230–9.CrossRefGoogle Scholar
  13. 13.
    Hassine M, Boussada M, Tahar M, et al. Infective endocarditis complicated by heart failure: characteristics and prognosis. Arch Cardiovasc Dis Supp. 2015;7:44–57.Google Scholar
  14. 14.
    Chambers HF, Morris DL, Tauber MG, et al. Cocaine use and the risk for endocarditis in intravenous drug users. Ann Intern Med. 1987;106:833–6.CrossRefPubMedGoogle Scholar
  15. 15.
    Moss R, Munt B. Injection drug use and right sided endocarditis. Heart. 2003;89:577–81.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Roberts WC, Buchbinder NA. Right-sided valvular infective endocarditis. A clinicopathologic study of twelve necropsy patients. Am J Med. 1972;53(1):7–19.CrossRefPubMedGoogle Scholar
  17. 17.
    Graupner C, Vilacosta I, San Roman J, et al. Periannular extension of infective endocarditis. J Am Coll Cardiol. 2002;39(7):1204–11.CrossRefPubMedGoogle Scholar
  18. 18.
    San Roman JA, Vilacosta I, Sarria C, et al. Clinical course, microbiologic profile, and diagnosis of periannular complications in prosthetic valve endocarditis. Am J Cardiol. 1999;83:1075–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Omani B, Shapiro S, Ginzton L, Robertson JM, Ward J, Nelson RJ, Bayer AS. Predictive risk factors for pericannular extension of native valve endocarditis. Clinical and echocardiographic analyses. Chest. 1989;96:1273–9.CrossRefGoogle Scholar
  20. 20.
    Chan K. Early clinical and long-term outcomes of patients with infective endocarditis complicated by perivalvular abscess. CMAJ. 2002;167(1):19–24.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Byrd BF, Shelton ME, Wilson BH, Schillig S. Infective perivalvular abscess of the aortic ring: echocardiographic features and clinical course. Am J Cardiol. 1990;66:102–5.CrossRefPubMedGoogle Scholar
  22. 22.
    Aksoy O, Sexton DJ, Wang A, Pappas PA, Kourany W, Chu V, Fowler Jr VG, Woods CW, Engemann JJ, Corey GR, Harding T, Cabell CH. Early surgery in patients with infective endocarditis: a propensity score analysis. Clin Infect Dis. 2007;44(3):364–72.CrossRefPubMedGoogle Scholar
  23. 23.
    Pongratz G, Pohlmann M, Gehling G, Bachmann K. Images in cardiovascular medicine. Pseudoaneurysm in the intervalvular mitral-aortic region after endocarditis and prosthetic aortic valve replacement. Circulation. 1997;96:3241–2.CrossRefPubMedGoogle Scholar
  24. 24.
    Xie M, Yuman L, Tsung O, et al. Pseudoaneurysm of the mitral-aortic intervalvular fibrosa. Int J Cardiol. 2013;166:2–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Bansal RC, Moloney PM, Marsa RJ, Jacobson JG. Echocardiographic features of a mycotic aneurysm of the left ventricular outflow tract caused by perforation of mitral-aortic intervalvular fibrosa. Circulation. 1983;67:930–4.CrossRefPubMedGoogle Scholar
  26. 26.
    Tiwari KK, Murzi M, Mariani M, Glauber M. Giant pseudo-aneurysm of the left ventricle outflow tract after aortic root replacement for extensive endocarditis. Eur J Cardiothorac Surg. 2009;36:399.CrossRefPubMedGoogle Scholar
  27. 27.
    Anguera I, Miro J, Vilacosta I, et al. Aorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality. Eur Heart. 2005;26:288–97.CrossRefGoogle Scholar
  28. 28.
    Krishna R, Casanova P, Larrauri-Reyes M, et al. Complete dehiscence and unseated prosthetic aortic valve causing severe aortic insufficiency: an unusual complication of prosthetic valve endocarditis. BMJ Case Rep. 2014; 206925.Google Scholar
  29. 29.
    Mullany CJ, Chua YL, Schaff HV, Steckelberg JM, Ilstrup DM, Orszulak TA, et al. Early and late survival after surgical treatment of culture-positive active endocarditis. Mayo Clin Proc. 1995;70:517–25.CrossRefPubMedGoogle Scholar
  30. 30.
    Choussat R, Thomas D, Isnard R, Michel PL, Iung B, Hanania G, et al. Perivalvular abscesses associated with endocarditis: clinical features and prognostic factors of overall survival in a series of 233 cases. Eur Heart J. 1999;20:232–41.CrossRefPubMedGoogle Scholar
  31. 31.
    Jault F, Gandjbakhch I, Chastre JC, Levasseur JP, Bors V, Gibert C, et al. Prosthetic valve endocarditis with ring abscesses: surgical management and long-term results. J Thorac Cardiovasc Surg. 1993;105:1106–13.PubMedGoogle Scholar
  32. 32.
    d’Udekem Y, David TE, Feindel CM, Armstrong S, Sun Z. Long-term results of surgery for active infective endocarditis. Eur J Cardiothorac Surg. 1997;11:46–52.CrossRefPubMedGoogle Scholar
  33. 33.
    Allan R, Hynes M, Burwash IG, Veinot JP, Chan KL. Coronary artery complications in infective endocarditis. Ann Thorac Surg. 2008;86(4):1381.CrossRefPubMedGoogle Scholar
  34. 34.
    Parashara DK, Jacobs LE, Kotler MN, Yazdanfar S, Speilman SR, et al. Angina caused by systolic compression of the left coronary artery as a result of pseudoaneurysm of the mitral-aortic intervalvular fibrosa. Am Heart J. 1995;129:417–21.CrossRefPubMedGoogle Scholar
  35. 35.
    Rozich JD, Edwards WD, Hanna RD, et al. Mechanical prosthetic valve associated strands: pathologic correlates to transesophageal echocardiography. J Am Soc Echocardiogr. 2003;16:97–100.CrossRefPubMedGoogle Scholar
  36. 36.
    Shapiro SM, Young E, De Guzman S, et al. Transesophageal echocardiography in diagnosis of infective endocarditis. Chest. 1994;105:377–82.CrossRefPubMedGoogle Scholar
  37. 37.
    Erbel R, Rohmann S, Drexler M, et al. Improved diagnostic value of echocardiography in patients with infective endocarditis by transoesophageal approach. A prospective study. Eur Heart J. 1988;9:43–53.PubMedGoogle Scholar
  38. 38.
    Sochowski RA, Chan K-L. Implication of negative results on a monoplane transesophageal echocardiographic study in patients with suspected infective endocarditis. J Am Coll Cardiol. 1993;21:216–21.CrossRefPubMedGoogle Scholar
  39. 39.
    Daniel WG, Mugge A, Martin RP, et al. Improvement in the diagnosis of abscess associated with endocarditis by transesophageal echocardiography. N Engl J Med. 1991;324:795–800.CrossRefPubMedGoogle Scholar
  40. 40.
    Afridi I, Apostolidou MA, Saad RM, Zoghbi WA. Pseudoaneurysms of the mitral-aortic intervalvular fibrosa: dynamic characterization using transesophageal echocardiographic and doppler techniques. J Am Coll Cardiol. 1995;25:137–45.CrossRefPubMedGoogle Scholar
  41. 41.
    Chan K, Cohen G, Sochowski R, Baird M. Complications of transesophageal echocardiography in ambulatory adult patients: analysis of 1500 consecutive patients. J Am Soc Echocardiogr. 1991;4:577–82.CrossRefPubMedGoogle Scholar
  42. 42.
    Evangelista A, Gonzalez-Alujas M. Echocardiography in infective endocarditis. Heart. 2004;90:614–7.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Ellis S, Godstein J, Popp R. Detection of endocarditis-associated perivalvular abscesses by two-dimensional echocardiography. JACC. 1985;5(3):647–53.CrossRefPubMedGoogle Scholar
  44. 44.
    Agirbasli M, Fadel B. Pseudoaneurysm of the mitral-aortic intervalvular fibrosa. Echocardiography. 1999;16(2):253–7.CrossRefPubMedGoogle Scholar
  45. 45.
    Feuchtner G, Stolzmann P, Dichtl W, et al. Multislice computed tomography in infective endocarditis. J Am Coll Cardiol. 2009;53(5):436–44.CrossRefPubMedGoogle Scholar
  46. 46.
    Nishimura R, Otto C, Bonow R, et al. AHA/ACC guidelines for the management of patients with valvular heart disease. Circulation. 2014;2014:129.Google Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Division of Cardiology, The Health Sciences CentreMemorial UniversitySt. John’sCanada
  2. 2.Department of CardiologyUniversity of Ottawa Heart InstituteOttawaCanada

Personalised recommendations